About a year after Blanco County launched its community health paramedicine program in 2022, paramedic Wesley Patton was referred to a patient in the local jail. The man had been arrested on terroristic threat charges tied to his substance use.
Community paramedicine is largely about being proactive and working with vulnerable people to help improve their health before they need emergency care. So Patton visited the man in jail to talk about options once he was released. Over several months Patton continued meeting with the patient and the man’s family. Once free, the man entered a rehabilitation program, Patton said.
“He has fully turned his life around,” Patton said. “I talked to him the other day, and he said, ‘I finally realized that life is more fun without drugs.’”
Community paramedicine programs started in the U.S. in the 1990s to address the increase in 911 usage and limit emergency department crowding, which can result in delayed service and poor-quality care. Emergency services departments around the country created teams of specially trained paramedics to reach the people most likely to need help and provide more comprehensive care. Much of the work for someone like Patton involves doing outreach, often to people with untreated mental health issues, and directing them to services in the area so they receive help before they’re in crisis. It can also involve providing in-home care to people who lack transportation or are dealing with substance use disorder.
“EMS is no longer just an ambulance or a taxi driver that shows up and takes the patient from location A to location B,” said Dr. Heidi Abraham, the chief deputy medical director for Austin-Travis County EMS and the medical director for the New Braunfels Fire Department and Blanco County EMS. “EMS is able to meet all of these patients where they are and provide them care that is very much tailored to their circumstances and their environment.”
But while the programs have proliferated in major Texas cities, the demand for community paramedicine in rural areas remains unmet. Patton is one of two community health paramedics serving the 13,000 people in Blanco County west of Austin.
Rural communities in Texas overwhelmingly lack mental health resources. This can lead to high levels of crisis care in these communities and costly incarcerations of people with mental illnesses. The Texas Department of State Health Services estimates that providing care to rural Texans experiencing a mental health crisis costs $982 million annually, with $661 million going to ER charges and $248 million to incarceration costs. Suicide rates are higher in Texas’s non-metro areas.
Yet rural health care providers are struggling to find funding for the community paramedicine programs. And unlike other states, Texas has no regulations for CHP programs. Programs vary in structure and the kind of resources they can access. Small cities often struggle to finance their programs, while the ones in bigger cities have higher success rates. The lack of data to prove their effectiveness also makes it hard for community paramedics to advocate for funding.
Community programs fill gaps in patchy health system
Kim Griffith started reevaluating her role as a traditional emergency paramedic after she responded to a crisis call for a patient who had not been taking their prescribed medication, which only cost a few dollars.
“We [paramedics] do a phenomenal job of stabilizing people, but many times we run into people where we’re like, this didn’t need to happen to begin with,” said Griffith, who worked as a traditional paramedic for 10 years.
This patient’s situation prompted Griffith to make the switch to community paramedicine, a model that allows her to serve her community with preventative, primary, and mental health care services. Unlike her old position where she would only see patients on an emergency scene, Griffith said she can now routinely visit the same patients to monitor how they’re doing, acting as a safety net for those who need support outside of emergency medical care. Community paramedics operate under the umbrella of mobile integrated health care, which one study described as “a patient-centered, innovative delivery model offering on-demand, needs-based care and preventive services, delivered in the patient’s home or mobile environment.”
Sometimes community paramedics end up offering some sort of basic care that a person without regular access to a physician would have sought in the emergency room. They also often end up filling the gap in mental health or substance use treatment.
Each one of my patients has been failed in some way. Some sort of system failed them in order for them to continuously rely on 911.
Ashley Cammack, New braunfels mobile integrated health specialist
Research states that the capacity of emergency health care systems lags demand, and the market-based health care system in the U.S. results in emergency resources that are disproportionately located in wealthy areas, resulting in inequitable care for lower income populations and minorities. These gaps in care are particularly evident in Texas, which consistently ranks among the worst in the country for access to mental health care.
Community paramedics fill these health care gaps by providing at-home care and educating patients about outside resources. For example, community health paramedics in Austin meet with people who recently survived overdoses, discuss options like recovery and can provide some patients with opioid maintenance medications that reduce cravings, actually visiting them where they live. In many departments, this is done by EMS or law enforcement officers referring frequent 911 utilizers to a community paramedicine list, where community paramedics will be able to contact patients and assist with their health care needs. Frequent 911 utilizers are typically defined as people who call 911 more than 10 times, but programs use different numbers for classifying these individuals based on community trends.
“With anybody who utilizes 911 frequently, there’s some sort of mental health component because in most people’s rational thinking 911 is used specifically for emergencies,” said Ashley Cammack, New Braunfels MIH specialist. “It is an emergency for them. That’s where education and connection come in.”
Community paramedics are trained in mental health de-escalation tactics and may arrive at calls in more casual clothes; they’re better equipped to help people experiencing a mental health crisis, which otherwise might lead to incarceration. The National Conference of State Legislatures (NCSL) said that due to lack of access to alternatives, law enforcement can spend one-fifth of its time responding to and transporting individuals with mental illness to emergency departments or jails.
Gaps in the mental health care system have resulted in high rates of incarceration for people with mental illnesses, with an estimated 2 million incarcerated nationally each year. Once in jail or prison, people with serious mental illness are incarcerated for longer than other people and are more likely to be victimized, exacerbating their psychological conditions, according to researchers.
For people of color with mental illnesses, the risk of incarceration is especially pronounced. Once incarcerated, Black and Hispanic Americans with mental illness are 2.5 times more likely to experience solitary confinement. People with mental illness are also more likely to die during encounters with law enforcement. Non-Black Hispanics with a mental illness are almost three times more likely to die during an encounter than those without.
“The benefit to the person in need of care is that no matter how volatile or how unpredictable or how disruptive their health care emergency is, they can have something besides the cops delivering that care,” said B.J. Wagner, executive vice president for health and public safety at the Meadows Mental Health Policy Institute.
Texas community paramedics say these programs have improved patient quality of life and reduced overutilization of 911. Chinyere Okoh, a doctoral graduate at the University of Texas at Austin who conducted a cross-sectional survey examining community health paramedicine professionals, found that the CHP initiative has done well in providing value-based and patient-centric care.
To her, community paramedics offer an antidote to something she often hears about: distrust in the health care system.
“Community paramedicine provides an avenue to ensure that health quality is always being checked. The patients trust them,” she said. “When you trust someone, you’re likely to really remember their instructions. You’re likely to form a relationship with them, and you’re likely to be assured that they’re there for you, that they have your best interest at heart.”
Rural programs meet a need, but struggle
Patton, 41, began his career in Mississippi, volunteering for fire and EMS stations at age 16 and earning his EMT license at 18. When he relocated to Blanco County, he realized how little health care support and resources people had. The only resource they have for mental health is the Hill Country Mental Health and Developmental Disabilities Center. He wanted to help.
“In Blanco County, we do not have a hospital,” he said. “We do not have a standalone ER. We do not have urgent care. If you need specialty service, you have to go outside of Blanco County.”
When the program, which covers the municipalities of Blanco, Johnson City and Round Mountain, launched three years ago, the need was quickly obvious. Patton said he expected it would take six months to ramp up the program.
“In a matter of about six weeks, I had probably 40 patients that I was already working with,” he said.
According to NCSL, over 40 states have launched CHP or MIH programs since the model’s creation, but Texas has no health care regulations related to community paramedics, largely leaving EMS medical directors to determine where paramedics practice and what roles they fill.
This lack of regulation for community paramedicine in Texas is a double-edged sword. While it gives communities the freedom to curate programs that will benefit their patients the most, it limits access to consistent funding since there isn’t a universal program model. Large cities, like Austin or Dallas, have big staffs and multiple initiatives, while smaller towns can barely keep a few community paramedics going.
In Austin, where Griffith works, the CHP program began in 2006 and has since split into six response and support sections. EMS has connected over 3,000 patients with Austin’s CHP team and made over 1,300 referrals to outside sources to assist these patients in getting the care they need.
The Rapid Integrated Group Healthcare Team (RIGHT Care) in Dallas follows a similar structure and was established to address the high rate of mental health crises in South Central Dallas. Each team they deploy consists of three individuals: one paramedic, one law enforcement officer and one licensed mental health clinician. Between January and November 2024, these teams took around 12,216 calls and served 6,873 people.
“Austin, San Antonio, Dallas — all of these are our city-based areas where it’s easier for them to move money,” said Corey Naranjo, a community paramedic and registered nurse in Houston.
But the smaller rural and suburban communities don’t easily find success, despite the fact that the need for emergency and crisis care is particularly acute in rural Texas. Mental health issues occur at roughly the same rates in urban and rural areas, but people in rural areas are less likely to receive treatment, according to official statistics and studies in Texas and elsewhere. The 2020 suicide rate in non-metro areas of Texas was 1.5 times higher than in metro areas, according to a report by Texas Health and Human Services. That same report found that rural areas face a shortage of primary care providers.
“Adults in rural areas receive less frequent mental health services, are often treated by medical providers who do not specialize in mental health treatment, and may receive less care coordination,” researchers wrote. “Additionally, many health providers such as hospitals, health clinics, and mental health inpatient facilities are located in more populated areas, potentially making it burdensome for rural Texans to access resources that can be several hours away.”
Similar to Patton, Cammack fell in love with fire and EMS at 16 and never looked back. She was a firefighter for 13 years and a paramedic for five years before becoming a community paramedic in January 2024.
Cammack’s first day of service was in February 2024, and she remains New Braunfels’ sole community paramedic. Cammack currently monitors 55 patients, with a threshold of working with around 10 patients per week.
“It’s very complicated, but I’m absolutely doing my best and trying to make sure everyone still feels heard and seen, making sure my patients are taken care of as much as I can,” she said.
New Braunfels MIH program was formed to educate high-frequency 911 utilizers on the appropriate use of emergency services and provide them with alternative resources to address their needs.
“Each one of my patients has been failed in some way. Some sort of system failed them in order for them to continuously rely on 911,” Cammack said. One patient received medical equipment at her home but didn’t have the hand mobility to put it together. Other patients couldn’t afford food and weren’t able to visit local food banks. Some had underlying issues with substance abuse, family trauma or homelessness and didn’t have access to the appropriate resources.
According to Abraham, the chief deputy medical director for Austin-Travis County EMS, preventable health care situations like these can exacerbate patients who are already in a vulnerable state.
While both Cammack and Patton hope to expand their programs, it’s difficult to do so when there are challenges maintaining consistent funding and onboarding more than one CHP professional — particularly for the rural and suburban areas they oversee.
The Blanco County program is funded by taxpayer money, county grants and the two Emergency Service Districts (ESD) that preside over Blanco County’s emergency responses. The New Braunfels program is funded by a grant from the McKenna Foundation. Cammack said the grant application and approval process took five years.
Programs in other small cities have already closed or are in the risk of closing. In Deaf Smith County, a rural area on the western edge of the Panhandle, the CHP program is only funded until March 2026. Terry Hazlett, who oversees the program, said they’re still trying to find a way to continue after their grant ends.
The funding limitations create further dilemmas because CHP programs often don’t exist long enough to collect data. “Statistics and data go hand-in-hand with funding since investors like to know their money is being used efficiently,” Hazlett said.
“We do not have a systematic approach for collecting data. In order to receive funding, you must have the data to support the funding,” she said.
The lack of accessible data is a challenge for researchers and program facilitators as well because it limits the reliable information that can be put out about these initiatives.
“The health care needs and funding resources really determine the type of programs, but I encountered some challenges with limited data about community paramedics, particularly in the United States,” said Okoh.
Okoh said that CHP programs are so new that many people are unaware of what they do and how helpful they can be.
“They’re doing great work, but they’re not really being supported by the health care system, and there’s a need for federal government funding,” Okoh said.
Between 2021 and 2023, Texas proposed at least three house bills, House Bills 639, 3161, and 3467, relating to the official establishment of community paramedicine programs and the preventative health care services they provide. Two of the bills died in committee, and one died in the chamber.
In 2024, the U.S. House of Representatives received a proposition for the Community Paramedicine Act of 2024, which introduces the idea of awarding grants to qualified institutions for supporting community paramedicine programs. The last action on this bill was a referral to the U.S. Subcommittee on Health on April 26, 2024.
“It’s sad because I would assume that the government would see a lot of benefits when it comes to community paramedicine,” Okoh said. “Maybe they’re not really being informed in the right way about the need for these individuals, because community paramedics are health care providers.”
Blanco County has embraced its community paramedicine program, Patton said. The Hill Country Mental Health and Developmental Disabilities Center recently received grant funding to embed a qualified mental health professional with his team. Now, that mental health provider accompanies the community health paramedics on calls during the week.
“People are very on board with it in our county,” he said. “It’s an extra resource to try to help people.”
Texas Community Health News is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center and newsrooms in selected states across the country.